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Silent sinus syndrome
Silent sinus syndrome (SSS), or imploding sinus syndrome as it is also known, is a rare
disorder involving the maxillary antrum, characterized by an indolent course of subclinical
maxillary sinusitis that leads to progressive contraction of the maxillary sinus.
This process can eventually lead to prolapse of the orbital contents, enophthalmos, and
ensuing ocular symptomatology.
Epidemiology
SSS most commonly presents in the third to fourth decades of life
Male : Female is equal
● Although quite rare, SSS may occur in pediatric patients and should be
considered when treating a young patient with facial asymmetry or enophthalmos.
Pathophysiology
SSS is believed to originate from obstruction of the ostiomeatal complex of the paranasal
sinuses leading to hypoventilation of the maxillary sinus.
This enclosed cavity in certain settings is thought to develop air resorption, thus creating
a suction effect of negative pressure within the maxillary antrum.
accumulation of mucus into the antrum, subclinical inflammation, and eventual collapse of
the maxillary sinus through attenuation of the maxillary bony side walls.
The key to SSS is its subclinical nature despite the presence of obstructed ostia and
subsequent long-standing duration of negative barometric pressure.
Clinical Features
● The difficulty in presentation of SSS is that patients with this disorder do not have
any traditional maxillary or other paranasal sinus complaints.
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● The average duration of the progressive, characteristic orbitopathies until
presentation is 3 months (range 10 days–2 years).
● Patients with SSS present with spontaneous enophthalmos and hypoglobus
resulting from ipsilateral attenuation of the walls of the maxillary antrum in the
absence of clinically evident maxillary sinusitis
● Patients will occasionally complain of double vision, but they generally have
normal ocular motility and vision.
On examination:
- Orbital asymmetry due to unilateral enophthalmos and it's the most common
presentation.
- the average orbital recession is 2-3 mm , with 53% of patients presenting with
hypoglobus and an average orbital decline of 2.5-3 mm
- eyelid retraction
- narrowing of palpebral fissure
- lagophthalmos.
● On nasal endoscopy, patients may have subtle alterations, such as a widened
middle meatal cavity with inward / retraction of the uncinate process.
● Alternatively, the middle meatus may be obscured on the endoscopic exam due
to lateral displacement of the middle turbinate toward the uncinate process.
Radiographic evaluation
● CT imaging is the gold standard and it’s essential to confirm the diagnosis of SSS
● To evaluate characteristic changes to the orbit and the paranasal sinuses

● The classic CT finding in SSS is the inward retraction of the medial and superior
walls of the maxillary sinus associated with a decrease in the maxillary antral
volume
● Additional findings include :
1. well-developed but opacified maxillary sinus,
2. occlusion of the maxillary infundibulum due to retraction of the uncinate
process
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3. expanded middle meatus with increased orbital volume .
The differential diagnosis
It include other etiologies resulting in enophthalmos, such as
❖ trauma to the orbit ( especially blowout fracture of the orbital floor),

❖ prior orbital decompression for Graves orbitopathy (especially if one fails to
preserve the bony strut between the medial and inferior orbital wall),
❖ CRS, osteomyelitis, Wegener granulomatosis, orbital metastasis,
❖ human immunodeficiency virus (HIV) lipodystrophy, and prior orbital radiation
therapy
❖ Exceedingly rare disorders in the differential are orbital fat atrophy,
Recklinghausen disease ( absence of the sphenoid wing), linear scleroderma,
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Parry- Romberg syndrome (progressive hemifacial atrophy), and
pseudoenophthalmos.
● SSS is actually in the spectrum of maxillary atelectasis.

● Brandt and Wright defined three stages of the disease, with stages I and II
entailing CRS symptoms in conjunction with classic CRS anatomical findings, and
stage III form as the final pathway that often results in an asymptomatic
spontaneous enophthalmos, which defines SSS.
● In their review of the literature, they dentified that as patients have increased
bone changes, they appear to have decreased symptoms, although the exact
reason for this remains unclear.
Treatment
● The major concern during treatment is inadvertent entry into the orbit due to
underlying anatomical changes from the disease process.
● It is critical to obtain a detailed preoperative CT scan to assess the anatomical
relationships prior to intervention.
Initially, a complete uncinectomy should be performed.
● Due to the inferior displacement of the orbital contents and atelectatic uncinate,
there is an increased risk of orbital injury.
● Traditional uncinectomy techniques, such as the use of a sickle knife to incise the
uncinate at the anterior attachment to the lacrimal bone, is discouraged, as this
can result in penetration through the lamina papyracea. In this instance, the use
of a ball-tip probe to identify the free margin of the uncinate and refl ect it forward
away from the orbit will provide a safer dissection away from the lamina
papyracea.
● Anterior ethmoidectomy for added exposure of the hiatus semilunaris and medial
orbital wall •
● Inferior meatal antrostomy with possible endoscopic medial maxillectomy in select
cases
In addition to relieving maxillary sinus ostium obstruction, SSS may necessitate a second
surgical procedure to restore the height of the orbital floor.
● This procedure would be indicated for persistent orbitopathy following primary

surgical intervention to restore orbital volume and symmetry.
● There is a debate in the literature regarding one- or two-stage approach.
● The authors of this chapter advocate a two-stage approach. Patients are
monitored with close observation for at least 6 to 12 months after ESS.
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● This allows for full resolution of any possible infectious agents found in the
operated antrum prior to placement of a foreign material implant, and also allows
for the possibility of natural resolution of orbital findings and subjective
complaints.

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Silent sinus syndrome

Male : Female is equal

● To evaluate characteristic changes to the orbit and the paranasal sinuses

The differential diagnosis

It include other etiologies resulting in enophthalmos, such as

❖ trauma to the orbit ( especially blowout fracture of the orbital floor),

● SSS is actually in the spectrum of maxillary atelectasis.

Initially, a complete uncinectomy should be performed.

● This procedure would be indicated for persistent orbitopathy following primary

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